两种胆道支架置入术治疗恶性梗阻性黄疸的临床对比研究
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摘要
目的：探讨经内镜胆道支架置入及经皮经肝穿刺胆道支架置入术在恶性梗阻性黄疸患者临床治疗中的应用价值及选择。
方法：回顾性分析2006年12月至2010年12月我院恶性梗阻性黄疸患者10)3例,按不同治疗方法分为经内镜逆行胆道支架置入术组(61例)及经皮经肝穿刺胆道支架置入术组(42例),比较经不同治疗方法后恶性梗阻性黄疸患者近期肝功能的恢复,不同类型恶性梗阻性黄疸行内镜胆道支架置入及经皮经肝穿刺胆道支架置入的成功率及相关并发症发生率。
结果：经内镜胆道支架置入术和经皮经肝穿刺胆道支架置入术成功率分别为81.96%和90.48%,经皮经肝穿刺胆道支架置入术在Ⅳ型肝门胆管癌治疗成功率存在明显优势(P<0.05)；在术后胆道出血并发症方面经皮组高于内镜组(P<0.05)；胰腺炎发生率内镜组高于经皮组(P＜0.05)。两组治疗在减黄,肝功能恢复方而无显著性差异。
结论：胆道支架经内镜置入及经皮经肝穿刺置入均可有效解除恶性梗阻性黄疽患者胆管梗阻,改善肝功能；肝门胆管癌BismuthⅣ型治疗以经皮经肝穿刺胆道支架置入术为佳,肝门胆管癌BismuthⅢ型根据患者具体梗阻情况选择相应胆道支架置入术,肝门管癌BismuthⅠ型、Ⅱ型及壶腹周围癌首先建议内镜治疗,若不成功再行经皮经肝胆道支架置入治疗。经内镜胆道支架置入术后出现胰腺炎并发症儿率较高,经皮经肝穿刺胆道支架置入术后出现胆道出血并发症几率较高,术后应注意预防及早期发现、早期治疗,临床应根据患者的具体情况选择不同的置入方式,提高安全性及有效性,尽可能减少并发症的发生。
Objective To compare the short-term efficacy and to evaluate the indication of two kinds of palliative treatment in patients with malignant obstructive jaundice.
Methods In December 2006 to December 2010 in our hospital palliative treatment of concurrent treatment 103 patients with malignant obstructive jaundice were selected, according to their different treatment methods who were divided into percutaneous transhepatic biliary stenting (PTBS) group (61 cases) and endoscopic retrograde biliary stenting (ERBS) group (42 cases), the recent recovery of liver function, the morbidity rate and the success rate of different treatment methods in the different types of malignant obstructive were evaluated.
Result The success rate of PTBS and ERBS was 81.96% and 90.48% respectively. there was significant difference between the two treatment methods in complications of the pancreatitis and biliary tract bleeding (P<0.05); In theⅣtype hilar cholangiocarcinoma the treatment success rate of percutaneous transhepatic stenting was obviously advantageous.
Conclusion There is advantages and disadvantages in the complications of two treatment methods, For the treatment ofⅣtype hilar cholangiocarcinoma percutaneous transhepatic biliary stenting should be favored, forⅠandⅡtypes of hilar cholangiocarcinoma and periampullary carcinoma endoscopic retrograde biliary Stenting is indicated,and forⅢtype of hilar cholangiocarcinoma one of the two palliative treatment should be chosen is according to the specific circumstanced.
方法：回顾性分析2006年12月至2010年12月我院恶性梗阻性黄疸患者10)3例,按不同治疗方法分为经内镜逆行胆道支架置入术组(61例)及经皮经肝穿刺胆道支架置入术组(42例),比较经不同治疗方法后恶性梗阻性黄疸患者近期肝功能的恢复,不同类型恶性梗阻性黄疸行内镜胆道支架置入及经皮经肝穿刺胆道支架置入的成功率及相关并发症发生率。
结果：经内镜胆道支架置入术和经皮经肝穿刺胆道支架置入术成功率分别为81.96%和90.48%,经皮经肝穿刺胆道支架置入术在Ⅳ型肝门胆管癌治疗成功率存在明显优势(P<0.05)；在术后胆道出血并发症方面经皮组高于内镜组(P<0.05)；胰腺炎发生率内镜组高于经皮组(P＜0.05)。两组治疗在减黄,肝功能恢复方而无显著性差异。
结论：胆道支架经内镜置入及经皮经肝穿刺置入均可有效解除恶性梗阻性黄疽患者胆管梗阻,改善肝功能；肝门胆管癌BismuthⅣ型治疗以经皮经肝穿刺胆道支架置入术为佳,肝门胆管癌BismuthⅢ型根据患者具体梗阻情况选择相应胆道支架置入术,肝门管癌BismuthⅠ型、Ⅱ型及壶腹周围癌首先建议内镜治疗,若不成功再行经皮经肝胆道支架置入治疗。经内镜胆道支架置入术后出现胰腺炎并发症儿率较高,经皮经肝穿刺胆道支架置入术后出现胆道出血并发症几率较高,术后应注意预防及早期发现、早期治疗,临床应根据患者的具体情况选择不同的置入方式,提高安全性及有效性,尽可能减少并发症的发生。
Objective To compare the short-term efficacy and to evaluate the indication of two kinds of palliative treatment in patients with malignant obstructive jaundice.
Methods In December 2006 to December 2010 in our hospital palliative treatment of concurrent treatment 103 patients with malignant obstructive jaundice were selected, according to their different treatment methods who were divided into percutaneous transhepatic biliary stenting (PTBS) group (61 cases) and endoscopic retrograde biliary stenting (ERBS) group (42 cases), the recent recovery of liver function, the morbidity rate and the success rate of different treatment methods in the different types of malignant obstructive were evaluated.
Result The success rate of PTBS and ERBS was 81.96% and 90.48% respectively. there was significant difference between the two treatment methods in complications of the pancreatitis and biliary tract bleeding (P<0.05); In theⅣtype hilar cholangiocarcinoma the treatment success rate of percutaneous transhepatic stenting was obviously advantageous.
Conclusion There is advantages and disadvantages in the complications of two treatment methods, For the treatment ofⅣtype hilar cholangiocarcinoma percutaneous transhepatic biliary stenting should be favored, forⅠandⅡtypes of hilar cholangiocarcinoma and periampullary carcinoma endoscopic retrograde biliary Stenting is indicated,and forⅢtype of hilar cholangiocarcinoma one of the two palliative treatment should be chosen is according to the specific circumstanced.
引文
[1]何庆良,石铮,林永堃.晚期恶性阻塞性黄疸的姑息性手术疗效探讨.中国普通外科杂志.2001,1()(1)：77-78.
[2]戴放,黄信华,陈勇等.胆道支架外科分流术姑息性治疗恶性梗阻性黄疽临床疗效对比分析.中华肝胆外科杂志,2001,7(2)：100—103.
[3]Bismuth H, Nakache R, Diamond T. Management strategies in resection for hilar cholangiocarcinoma[J]. Ann Surg,1992,215:31—38.
[4]Coqling MG, Adam AN. Internal stenting in malignant biliary obstruction[J]. World J Surg,2001,25:355-359.
[5]Shim CS, Iee YH, Cho YD, et al. Preliminary results of a new covered biliary metal 8tent for malignant biliary obstruction[J]. Endoscopy,1998,30:345—350.
[6]孙陵,吕朋华,王立富,等.恶性梗阻性黄疸的介入治疗和疗效分析[J].实用临床医药杂志,2009,133(4)：110-111.
[7]Schoder M, Rossi P, Uflacker R, et al. Malignant biliary obstruction:treatment with PTFE-FEP-covered endoprostheses initial technical and clinical experiences in a multicenter trial[J]. Radiology,2002,225(1):35-42.
[8]石景森,周连锁,王作仁等.肝外胆道癌830例临床术分析[J].中华外科杂志,1997,35(11)：645—648.
[9]Nimura Y,Haya N,Kamiya J,et al..Hepatectomy for hilar blie duct cancer[J]. Asian J Surg,1996,19:94-96.
[10]王小林主编.腹部介入放射学[M].上海医科大学出版社,1998.113.
[11]刘会春.恶性梗阻性黄疸的姑息性减减黄术[J].肝胆外科杂志,2009,17(3)：166-168.
[12]Holt A P, Patel M,Ahmed M M. Palliation of Patients with Malignant Gast roduodenal Obst ruction with Self-expanding Metallic Stents:the Treatment of Choice[J]. Gast rointest Endosc,2004,60 (6):1010.
[13]Besser P. Percutaneous Treatment of Malignant Bile Duct Sci Monit Strictures in Patients Treated Unsuccessfully with ERCP[J]. Med,2001,7:120.
[14]Hiroshi Yoshida, Yasuhiro Mamada, Nobuhiko Taniai, et al.One-step Palliative Treatment Method for Obstructive Jaundice Caused by Unresectable Malignancies by Percutaneous Transhepatic Insertion of an Expandable Metallic Stent [J]. World J Gastroenterol,2006,12 (15):2423.
[15]谢宗贵,张希全,李凡东等.胆道支架技术5年回顾(213例随访报告[J].中·华肝胆外科杂志,2002,88(1())595-597.
[16]Rossi P, Bezzi M, Rossi M, et al. Metallic stents in malignant biliary obstruction: results of a multicenter European study of 240 patients [J]. J Vase Interv Radiol, 1994,5(2):279-285
[17]Rerknimitr R, Kladcharoen N,Mahachai V, et al.Result of endoscopic biliary drainage in hilar cholangiocarcinoma [J].J Clin Gastroenterol,2004,38: 518.
[18]Inal M, Akgul E, Aksungur E, et al. Percutaneous self-expandable uncovered metallic stents in malignant biliary obstruction. Complications, follow-up and reintervention in 154 patients. Acta Radiol.2003,44(2):139-146.
[19]钱晓军,翟仁友,戴定可,等.老年人恶性梗阻性黄疸介入治疗回顾性分析[J].中华放射学杂志,2000,34(5)：342.
[20]王庆,秦明放,勾承月,等.经内镜胆道支架置入术姑息性治疗肝门部胆管癌的临床应用[J].中国内镜杂志,2008,14(9)：1003.
[21]姜水继,郑萍,曾发,等.经皮肝穿胆道引流及支架置入的并发症分析[J].医学信息,2009,22(7),38-40.
[22]翟仁友,黄强.恶心梗阻性黄疸介入治疗常见问题的处理[J].介入放射学杂志,2007,16(1())：649.
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[2]戴放,黄信华,陈勇等.胆道支架外科分流术姑息性治疗恶性梗阻性黄疽临床疗效对比分析.中华肝胆外科杂志,2001,7(2)：100—103.
[3]Bismuth H, Nakache R, Diamond T. Management strategies in resection for hilar cholangiocarcinoma[J]. Ann Surg,1992,215:31—38.
[4]Coqling MG, Adam AN. Internal stenting in malignant biliary obstruction[J]. World J Surg,2001,25:355-359.
[5]Shim CS, Iee YH, Cho YD, et al. Preliminary results of a new covered biliary metal 8tent for malignant biliary obstruction[J]. Endoscopy,1998,30:345—350.
[6]孙陵,吕朋华,王立富,等.恶性梗阻性黄疸的介入治疗和疗效分析[J].实用临床医药杂志,2009,133(4)：110-111.
[7]Schoder M, Rossi P, Uflacker R, et al. Malignant biliary obstruction:treatment with PTFE-FEP-covered endoprostheses initial technical and clinical experiences in a multicenter trial[J]. Radiology,2002,225(1):35-42.
[8]石景森,周连锁,王作仁等.肝外胆道癌830例临床术分析[J].中华外科杂志,1997,35(11)：645—648.
[9]Nimura Y,Haya N,Kamiya J,et al..Hepatectomy for hilar blie duct cancer[J]. Asian J Surg,1996,19:94-96.
[10]王小林主编.腹部介入放射学[M].上海医科大学出版社,1998.113.
[11]刘会春.恶性梗阻性黄疸的姑息性减减黄术[J].肝胆外科杂志,2009,17(3)：166-168.
[12]Holt A P, Patel M,Ahmed M M. Palliation of Patients with Malignant Gast roduodenal Obst ruction with Self-expanding Metallic Stents:the Treatment of Choice[J]. Gast rointest Endosc,2004,60 (6):1010.
[13]Besser P. Percutaneous Treatment of Malignant Bile Duct Sci Monit Strictures in Patients Treated Unsuccessfully with ERCP[J]. Med,2001,7:120.
[14]Hiroshi Yoshida, Yasuhiro Mamada, Nobuhiko Taniai, et al.One-step Palliative Treatment Method for Obstructive Jaundice Caused by Unresectable Malignancies by Percutaneous Transhepatic Insertion of an Expandable Metallic Stent [J]. World J Gastroenterol,2006,12 (15):2423.
[15]谢宗贵,张希全,李凡东等.胆道支架技术5年回顾(213例随访报告[J].中·华肝胆外科杂志,2002,88(1())595-597.
[16]Rossi P, Bezzi M, Rossi M, et al. Metallic stents in malignant biliary obstruction: results of a multicenter European study of 240 patients [J]. J Vase Interv Radiol, 1994,5(2):279-285
[17]Rerknimitr R, Kladcharoen N,Mahachai V, et al.Result of endoscopic biliary drainage in hilar cholangiocarcinoma [J].J Clin Gastroenterol,2004,38: 518.
[18]Inal M, Akgul E, Aksungur E, et al. Percutaneous self-expandable uncovered metallic stents in malignant biliary obstruction. Complications, follow-up and reintervention in 154 patients. Acta Radiol.2003,44(2):139-146.
[19]钱晓军,翟仁友,戴定可,等.老年人恶性梗阻性黄疸介入治疗回顾性分析[J].中华放射学杂志,2000,34(5)：342.
[20]王庆,秦明放,勾承月,等.经内镜胆道支架置入术姑息性治疗肝门部胆管癌的临床应用[J].中国内镜杂志,2008,14(9)：1003.
[21]姜水继,郑萍,曾发,等.经皮肝穿胆道引流及支架置入的并发症分析[J].医学信息,2009,22(7),38-40.
[22]翟仁友,黄强.恶心梗阻性黄疸介入治疗常见问题的处理[J].介入放射学杂志,2007,16(1())：649.
[1]Schoder M, Rossi P, Uflacker R, et al. Malignant biliary obstruction:treatment with PTFE-FEP-covered endoprostheses initial technical and clinical experiences in a multicenter trial[J]. Radiology,2002,225(1):35-42.
[2]石景森,周连锁,王作仁等.肝外胆道癌830例临床分析[J].中华外科杂志,1997,35(11)：645-648.
[3]Nimura Y,Haya N,Kamiya J,et al.Hepatectomy for hilar blie duct cancer[J]. Asian J Surg,1996,19:94-96.
[4]王小林主编.腹部介入放射学[M].上海医科大学、出版社,1998.133.
[5]Hartmann D, Jakobs R, Schilling D, et al. Endoscopic and radiological interventional therapy of benign and malignant bile duct stenoses [J]. Zentralbl Chir,2003,128(11):936-943.
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